Failure to Administer and Document Medications and Wound Care per Orders
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for two residents with complex medical needs. For one resident with diabetes mellitus, the Medication Administration Record (MAR) showed that prescribed doses of Lantus SoloStar (Insulin Glargine) were not documented as administered on two separate dates, despite an active physician order for nightly subcutaneous injections. There was no evidence in the MAR that the medication was given as ordered on those dates. Another resident with multiple diagnoses, including diabetes mellitus with foot ulcer, congestive heart failure, peripheral vascular disease, lymphedema, and MRSA infection, had physician orders for specific wound care treatments to multiple sites. Review of the Treatment Administration Record (TAR) and MAR revealed missing documentation for wound care treatments on several dates. Additionally, progress notes did not contain information regarding the completion of these wound treatments on the specified dates. The Director of Nursing confirmed that documentation should be completed when medications or treatments are administered.